Following the iPrEX study demonstrating efficacy of HIV preexposure prophylaxis (PrEP) with emtricitabine/tenofovir (FTC/TDF), the Centers for Disease Control and Prevention (CDC) last week issued interim PrEP guidance for high risk men who have sex with men (MSM).

While good news, questions and concerns remain. The CDC recommends PrEP only in high risk men who have sex with men (MSM). I fear that this recommendation may be misunderstood, as the guidelines do not stress behavior over identity enough. Providers should understand that sexual behavior can be different than how one identifies. Many MSM do not identify as gay or bisexual. Without proper attention to behavior, many patients who might be suited for PrEP may be missed. On the other hand, will providers erroneously assume that all MSM are high risk?

Taking the current PrEP regimen, FTC/TDF, on a long term basis is not an easy proposition. It is currently unclear whether commercial insurers will cover the cost of PrEP, which is estimated at over $10,000 a year. Will patients continue to take PrEP months into a costly regimen? For that matter, how long should PrEP continue? In addition, the iPrEX study demonstrated that PrEP was generally well-tolerated. However, FTC/TDF is not without adverse effects or toxicities, including potential renal dysfunction from the tenofovir component.

Patients also need access to knowledgeable and culturally competent providers if PrEP is to be effective. In terms of identity, it never ceases to amaze me to hear a colleague offer, “I don't have any gay, bisexual or transgender patients.” You do. You just don't know it. I practice in HIV medicine and lesbian, gay, bisexual and transgender health, so these questions are regularly addressed. But for many patients, a lack of provider knowledge and cultural competence will mean missed opportunities. The Gay and Lesbian Medical Association  is a great resource on LGBT health.

Although the CDC interim guidelines represent a clear advancement, much still remains to be answered. The Fenway Institute has further information on PrEP for clinicians. Expect to hear more on the subject at the forthcoming Conference on Retroviruses and Opportunistic Infections later this month. JAAPA

Travis Sherer is an HIV specialist at the Lenox Hill Retroviral Disease Center and at the Callen-Lorde LGBT Community Health Center's sexually transmitted infections clinic in New York, NY. He is on the board of directors of the Gay and Lesbian Medical Association.